Mind > Information > Factsheets and booklets by subject > Community care > Community care 2 - Systems for delivering mental health services

Copyright note for Mind factsheets: Both individuals and organisations are welcome to print and photocopy any complete factsheet from the 'Information' section of Mind's website. Organisations are free to distribute them to service users and colleagues, but must ensure they always use the latest version of the factsheet, as available on the website, at the time of distribution.

Introduction

This factsheet examines the way in which statutory community mental health services and community care services for people with mental health problems are delivered by health and social services, usually under joint arrangements, with both agencies working together to arrange, fund and/or manage services. These systems are called Care Management and Care Programme Approach.

Social services departments arrange community care services for many groups of 'vulnerable' people with vastly differing needs, including children, elderly people, people with learning disabilities and people with mental health problems.

The NHS (Health Authorities and Primary Care Trusts) arranges community health care services. Services are delivered by NHS Trusts and Primary Care Trusts or newly formed Mental Health and Social Care Trusts.

This fact sheet is targeted primarily towards users of mental health services, students and professionals. However carers may find this information useful.

The National Service Frameworks for Mental Health for England and Wales both for set out standards in several areas with the aim of ensuring that there are no unacceptable variations in mental health care. See fact sheet #1 - The spectrum of mental health services .

People with severe mental health illness problems form a small proportion of those with mental health problems but have very high rates of psychological and physical morbidity. People with severe mental health problems are also socially excluded, finding it difficult to sustain social and family networks, access education systems and obtain and sustain employment. People with recurrent or severe or enduring mental illness have complex needs which may require the continuing care of specialist mental health services working effectively with other agencies. [1] Most people manage very well with this care and benefit from living in the community, posing no risk to themselves or others. [2]

Standards 4 and 5 of the National Service Framework for England relate to ensuring effective services for people with severe mental illness.

Receive care which optimises engagement, anticipates or prevents a crisis, and reduces risk

Each service user who is assessed as requiring a period of care away from their home should have:

a copy of a written after care plan agreed on discharge which sets out the care and rehabilitation to be provided, identifies the care coordinator, and specifies the action to be taken in a crisis.

Standard 7 of the National Framework for Wales relate to care for service users and carers.

Effective high quality care based on the best evidence and including provision for the medical, physical, psychological and social needs of service users and carers.

Communication through services and within services must be robust, with mechanisms to ensure people cannot fall between the general service and specialist provision

All users of mental health services with complex and enduring needs must receive a structured formal assessment and should receive care which encourages engagement, anticipates or prevents a crisis, and reduces risk.

Caring for People 1989

This White Paper described how local authority social services departments organise and provide community care services (not community healthcare services). Its overall aim was to promote a range of community care services to enable vulnerable people to live in the community whenever possible.

However, the main impetus for the White Paper sprang from the need to do something about the growing demands on the social security budget. At this time, people were able to enter residential care homes (including privately run care homes) without a proper assessment of their needs. In addition, funding was automatically provided by the social security budget if the person had no independent means - there was no 'means test' to determine whether someone could contribute towards the cost of his or her care. Caring for People transferred the budget for residential care from the social security budget to the local authority social services department (the legal changes to allow this to happen was made in the NHS and Community Care Act 1990).

The NHS and Community Care Act 1990 made the legal changes necessary for the new arrangements set out in 'Caring for People'.

The Act made it a duty for local authorities to assess people for social care and support. People who 'appear to need community care services' are entitled to an assessment - the results of the assessment will determine whether services should be provided. The legislation also said that services would be provided 'within available resources'.

Recent case law following the introduction of the NHS and Community Care Act further clarified the duties of local authorities:

Both health and social services departments have special responsibilities and procedures for assessing a person's needs, deciding whether services are needed and, if so which services should be provided. This is termed care management 'where there is an entitlement to an assessment of services' and a Care manager' will then purchase services for the user.

Recent Government policy requires health and social services to completely integrate these two procedures for people with mental health problems, so that the social services assessment for community care services will be part of a person's Care Programme Approach assessment. It is important to know that there may be differences in the way social services approach community care compared with health services. There should be co-operation between the two but it may be that as a result of these differences, there is a gulf in aftercare provision. It is important to note that the statutory responsibility for providing health care services lies with the NHS and not with social services. [3]

Although Care Management is not referred to in the NHS and Community Care Act, it is detailed in community care guidance to local authorities.

Screening - a process to determine whether or not a person 'appears' to be in need of community care services at all. If he or she does not appear to be in need, then the duty of assessment does not arise. The local authority must carry out an assessment of a person's needs for community care services if "it appears that any person for whom they may provide or arrange for the provision of community care services may be in need of any such services" (the 1990 Act s.47(1) [4].

Social services cannot refuse the assessment if they think a person is probably not in need of services, as that decision can only be made following an assessment itself. Nor can it refuse to carry out an assessment on the basis that a lack of resources would mean that the authority would be unable in fact to provide services to the applicant. The obligation to assess is triggered once the applicant has crossed the threshold test that there may be some need for a service which the authority might be able to provide [5].

Urgency and level of assessment - social services decide how urgent the assessment is and also whether it appears to be straightforward or complex. The assessment must look at potential need for all services the local authority is under a duty or empowered to provide, not just a need for services which it does, in practice, provide [6]. Assessment should cover psychiatric, psychological and social functioning, risk to the individuals and others including previous violence and criminal record, and needs arising from co-morbidity, and personal circumstances including family or other carers, housing, financial, occupational status and physical health needs [7].

Assessment process and eligibility for services - if a person meets the criteria for a service, social services can decide to provide it. Once social services have decided that a service should be provided it must be provided regardless of resource limitations.

Care plan - The assessment should be recorded in writing and given in writing - together with the care plan - to the service user. The care plan shows how a person's needs will be met and which agencies will provide services. The National Service Framework states that all plans should be explicit about the responsibilities of all who have a role in providing care.

Charges - if charges are to be made for a service, the service user's financial resources should be assessed and a decision made about how much to charge. See fact sheet # 4 - Commissioning Services .

A regular review - there should be a regular review (or reassessment) to determine whether a service user's needs have changed. As a result of a review services may be increased, changed or withdrawn.

an assessment to determine whether a person needs community care services (services arranged and provided by social services)

a written care plan setting out what social services will do to meet the person's social care needs and the services that will be arranged for them

The Care Programme approach was introduced in 1991 in England. The responsibility for implementation rests with health authorities. Unlike the NHS and Community Care Act 1990, which covers services to vulnerable adults in general, the Care Programme Approach (CPA) applies only to people with mental health problems. Hospitals/Trusts have to arrange an individually assessed 'package of care' for all people about to be discharged. Community mental health services (outpatient services, community mental health teams) have to arrange CPA assessments for users of mental health services who live in the community. The Care Programme Approach applies to 'anyone in touch with secondary mental health services (health and social care)'.

Community mental health care and social care for people with mental health problems is generally organised within Community Mental Health Teams (CMHTs). These teams are multi-disciplinary - team members are employed by both health and social services. This means that health and social care services carry out their responsibilities for assessing a service user at the same time - the service user's CPA assessment also includes an assessment under the NHS and Community Care Act for the community care services arranged by social services departments.

If a person is being discharged from hospital there should be a discharge planning meeting with CPA and Community Care Assessments being carried out at the same time with the involvement of both health and social services.

In effect, the CPA is care management for people with mental health problems and also a way of coordinating their community mental health services.

Recent Government policy now requires health and social services to completely integrate the CPA and Care Management for people with mental health problems. This means that Community Care Assessments and CPA assessments will be carried out as a single assessment for users of mental health services. There will be a single care plan setting out how health and social services will meet the service user's needs. The plan will set out the community care services and community mental health services the service user will receive. The key worker is now known as the 'care co-ordinator'.

Despite there being a single assessment for people with mental health problems, the responsibilities of the NHS and social services departments remain the same. A person cannot be charged for any service arranged and delivered by the NHS. For community care services arranged and/or delivered by social services departments (and services they arrange jointly with another authority) charges may apply.

The Standard CPA is for people who require the support of only one agency. People on standard level will pose no danger to themselves or to others and will not be at high risk if they lose contact with services. The input of the full multidisciplinary community mental health team will not be required - service users on standard CPA will generally require the support of only one or two members of the team.

An example of standard CPA might be someone who has been assessed as needing a fortnightly visit by a community mental health nurse (CMHN) plus an appointment with the psychiatrist at the out-patient clinic every three months. The CMHN will be the care co-ordinator; the care plan will be the fortnightly visit, the outpatient appointment and any treatment (such as medication or counselling).

The enhanced CPA will be for people with complex mental health needs who need the input of both health and social services. People on enhanced CPA generally need a range of community care services and community mental health care services. This group of people may include those who have more than one clinical condition and also those who are hard to link with services and/or with whom it is difficult to maintain contact. Some people on enhanced CPA are thought to pose a risk if they lost contact with services. Generally speaking, enhanced CPA tends to apply to people with the more severe mental health problems such as schizophrenia or manic depression.

Welsh policy for developing mental health services is based upon the 1989 Mental Illness Strategy for Wales [8]. This policy is currently under review by the National Assembly for Wales, and a new Strategy was produced in 2000. The existing strategy sets out a community based, multi- agency model of care supported as appropriate by local hospital and residential services. The Guidance on the Care of People in the Community with a Mental Illness (Welsh Office, 1996) identifies best practice in the provision of care and support for people with mental heath problems living within a community setting.

Community care is provided by the NHS in partnership with local social services. Community Mental Health Teams (CMHTs) are the cornerstone of care provision, acting as a point of access from primary care to the specialist psychiatric services.

In the majority of cases initial contact and assessment will be via the general practitioner and other primary care workers, social workers and those working in the voluntary sector. Current guidance states that the outcome of any assessment will be a care plan developed with the patient, the professional/members of the CMHT and other appropriate parties, such as family. The care plan includes a date for review and all details are provided to the person's GP within a maximum of ten working days. An additional result of assessment is the allocation of a named individual or key worker who acts as the primary contact between the person receiving care and the providers of care, agreeing the care plan and monitoring progress/the need for any change/follow up action.

The CPA will be introduced across Wales for all people with a serious mental health problem and/or complex enduring needs by end December 2004 [9]. CPA combines Care Planning and Case Management and will complement and supplement the single joint assessment framework (currently being developed by the Welsh Assembly Government and initially for use in working with older people but who principles will apply across all adult groups). By the implementation period enhanced CPA should normally be in place for people with a psychotic illness, those with combinations of severe mental illness and a history of harming themselves or others, those who are homeless and those who are lone parents or caring for young children. All care plans for individuals on CPA should include explicit plans for responding to non-compliance and missed contact, including contacting the primary care team.

The CPA in Tameside is operated within a system which already has in place joint working arrangements. CPA assessments are carried out jointly (by health and social services) for people being discharged from psychiatric hospital care, and by Community Mental Health Teams for people referred to them who are living in the community.

New referral - usually this is via the GP to the community mental health team. Other examples of referral include the casualty department of domiciliary visits by psychiatrists. All new referrals receive a level 1 assessment.

Assessment (level 1) - Information is recorded under specific headings on the assessment form including personal history, presenting problem, symptoms, drug/alcohol use, physical health, previous health and previous solutions. The assessor will then write up an intervention plan.

Following level 1 assessment, a person may either be placed on minimum CPA (standard) or referred for a level 2 assessment.

Assessment (level 2) - the following are considered criteria for entry into level 2 CPA (enhanced):

Diagnosis - for people experiencing severe psychosis, for example, schizophrenia or manic depression.

Duration of treatment - for people with long term problems for whom discharge from services is unlikely.

CPA assessment at both levels includes a social services community care assessment - the two systems are completely integrated.

As part of the level 2 assessment, further, more detailed information is recorded on the assessment form, including information about risk and crisis and contingency plans.

Care will include regular contact with a care co-ordinator and will probably involve a number of services arranged and/or delivered by both health and social care authorities.

Risk management and risk assessment are regarded as key elements of the CPA. 'Crisis and contingency plans' must be included in the care plans of anyone on enhanced CPA. It is not obligatory for people on Standard CPA to have these crisis plans, but it is considered to be 'good practice'.

Crisis plans will set out what action needs to be taken when a service user's mental health is deteriorating rapidly. They will include, for example, strategies that have worked effectively in the past and details of a person who the service user responds to well in times of crisis.

Contingency plans will detail the arrangements made for the service user in the event that either the care coordinator is unavailable or that part of the care plan cannot be carried out at short notice. This could include, for example, details of alternative service providers who would be willing to provide interim support.

People who are 'in touch with secondary mental health services (health and social services)' are entitled to a CPA assessment. A person will usually need a referral to secondary services from his or her GP, although some Community Mental Health Teams will accept self-referrals. Sometimes people are referred from casualty departments.

'Secondary mental health services' can mean outpatient psychiatric services, in-patient psychiatric units and the Community Mental Health Team. GP and primary care services do not count as secondary mental health services.

People already in touch with secondary mental health services should have received a CPA assessment. They should have a care plan and a care coordinator who will keep in regular contact with them. They are entitled to be involved in the assessment process and can have carers with them at the assessment meeting (if this is what they want). The assessment should be carried out jointly by health and social services - it will include a social services' assessment for community care services as well as looking at health care needs. It will also be decided whether a person should be on standard or enhanced level CPA.

At the time of the assessment, the carer of the person being assessed can ask for his or her own assessment under the Carer's Recognition and Services Act. This assessment will look at the carer's needs and at whether support services can be provided, for example, respite services to allow the carer to have a break. Carers can only have an assessment if the person they are caring for is being assessed. See How to access services - information for carers factsheet.

Note: People do not have an automatic right to services - it is the assessment process itself which decides what the person's needs are and what services will be provided.

In England, the GP can refer the person you are caring for to your local mental health team so that they can carry out a Care Programme Assessment. Care Programme Approach assessment can be carried out at the same as NHS and Community Care Assessments particularly if the person is being discharged from hospital into the care of a community mental health team where health professionals work with social services staff in community mental health teams.

In Wales, the GP can refer the person you are caring for to your local mental health team so that they can carry out an assessment of the person's care needs.

A person must be in touch with secondary mental health services to be entitled to a CPA assessment. If the GP will not refer a person to services he or she has no right to a CPA assessment. If this happens there are a number of strategies people could follow to try and access community care services:

People who cannot access secondary mental health services can still approach social services for a general community care assessment under the NHS and Community Care Act 1990. Social services will only carry out the assessment if they decide that a person 'appears' to need services. They may argue that a person does not 'appear' to need services because he or she is not in touch with secondary mental health services and that therefore a duty to assess does not arise. People in this position can seek legal advice or contact their local Community Health Council for advice.

Whether or not a person needs a referral to a specialist mental health service is down to the individual judgement of the GP. One GP may think the person does not need a referral, whilst another may feel referral is necessary. If the GP refuses to refer, changing GP might be an option. Community Health Councils can advise about this.

Sometimes Community Mental Health Teams will accept self-referrals. This means that in some cases a person can approach them direct without the need for a referral from his or her GP. Policies on this differ, and it's best to check with the particular CMHT involved. Local Community Health Councils should also have information.

Statutory providers (the NHS and social services departments) are not the only agencies providing health and social care in the community. Voluntary organisations such as local Mind groups offer a range of different services for people with mental health problems, such as day centres, employment projects and befriending schemes. Many voluntary organisations will accept self-referrals. Details of local services are available from MindinfoLine.

Mind has produced a range of Understanding booklets, factsheets and brief guides addressing different mental health problems which relate to this topic.

These legal advice booklets are designed to help users of mental health services, their relatives and professionals to understand the Mental Health Act 1983 and related law. They should be read in conjunction with the Code of Practice.

Assertive Community Treatment of Persons with Severe Mental Illness Leonard I. Stein and Alberto B. Santos W.W. Norton, 1998, £19.95

Choice, Information and Dignity - Involving users and carers in care management and mental health John Carpenter and Silvia Sharaini The Policy Press, 1997, £13.95

Community Care: A reader (2nd edition) Eds. Joanna Bornat, Julia Johnson, Charmaine Pereira, David Pilgrim and Fiona Williams ( Oxford University Press, 1997) £13.99

Dancing with Angels David Crepaz-Keay, Chris Binns and Evelyn Wilson CCETSW, 1997, £8.00

Drug Treatment in Psychiatry: A guide for the community mental health worker Peter Tyrer, Phil Harrison-Read and Elizabeth van Horn Butterworth-Heinemann, 1997, £27.50

Guidelines on Equal Opportunities and Mental Health Jan Wallcraft and Jim Read Mind/UNISON, 1995, £2.50

Housing and Social Exclusion Ed. Fiona E. Spears Jessica Kingsley Publishers, 1999, £16.95

Mental Health Act Manual (7th Edition) Richard Jones (Sweet and Maxwell, 2001) £49.00

Mind the Law: Mind's evidence to the Government's Mental Health Act Review Team Margaret Pedler, (Mind, 1999)

Needs Assessment and Community Care - Clinical practice and policy making Ed. Steve Baldwin Butterworth-Heinemann, 1998, £16.99

20-25 Glasshouse Yard
London
EC1A 4JT
Carers Line 080 8808 7777
(10am-12noon, 2-4pm)
email: internet@carersnorth.demon.co.uk
web: www.carersnorth.demon.co.uk
Provides information and support for carers. Branches throughout the UK. Information on subjects such as benefits, residential care, respite care and the Carers Act.

MindinfoLine (Mind's telephone information Service)
Mind
PO Box 277
Manchester
M60 3XN
tel: 0845 766 0163 Mon to Fri 9.15am-5.15pm
web: www.mind.org.uk
Information service includes a database of local Mind services and other organisations. Gives basic information on legal rights.

Mind Legal Advice Line - Mondays, Wednesdays and Fridays 2.00pm to 4.30 p.m. 020 8519 2122.
Gives legal advice on mental health law and related areas by telephone or in writing, has a network of solicitors who have experience in mental health issues and who specialise in different areas of law.
Write to: Principal Solicitor, Mind's Legal Unit, Mind, Granta House, 15-19 Broadway, London E15 4BQ.

NHS Direct
Tel: 0845 4647
Web: www.nhsdirect.nhs.uk
24-hour helpline providing healthcare advice and information to the public. Enables callers to speak directly to experienced nurses, assists callers to make the right healthcare choice.

UK Advocacy Network (UKAN)
14-18 West Bar Green
Sheffield S1 2DA
Tel: 0114 272 8171
Email: ukan@can-online.org.uk
Web: www.comcom.org/acorn/ukan/htm
Supports, advises and represents a network of user-run advocacy groups.

References

[1] National Service Frameworks for Mental Health, Modern Standards and Service Models (1999)

[2] Trieman, N., Leff, J. and Glover, G. Outcome of long stay psychiatric patients resettled in the community: prospective cohort study. British Medical Journal 319, 13-16 (1999)

[3] The Mind Manual - Legal Rights and Mental Health 16th Update 2001. Mind

[4] ibid.

[5] ibid.

[6] ibid.

[7] National Service Frameworks for Mental Health, Modern Standards and Service Models (1999)

[8] Mental Illness - A Strategy For Wales, Welsh Office 1989

[9] A National Service Framework for Wales - Adult Mental Health Services (2002). Welsh Assembly Government.

Originally written by Jackie Golding. Updated by Carole Reid-Galloway, Mind Information Unit, June 2002